Child Intake Packet - ALPHA House of Pinellas Countyalphahousepinellas.org/wp-content/uploads/2016/10/Child...Page 7 of 31 ALPHA HOUSE OF PINELLAS COUNTY 701 5th Avenue North, St

Child Intake Packet

Page 1 of 31

Table of Contents:

1.) Admission Requirements...................................................................................page 2

2.) Emergency Data Sheet (Mother)........................................................................page 3-4

3.) HIPAA Release Forms.........................................................................................page 5-10

4.) Homeless Verification Form................................................................................page 11-12

5.) Emergency Data Sheet (Child).............................................................................page 13-14

6.) Emergency Medical Treatment...........................................................................page 15

7.) Guardianship Form..............................................................................................page 16

8.) Baby in Bed Contract...........................................................................................page 17

9.) Baby’s Birth Information.....................................................................................page 18

10.) Cell Phone Policy...............................................................................................page 19

11.) Consent Form...................................................................................................page 20

12.) Drug and Alcohol Consent Form........................................................................page 21

13.) Grievance Form.................................................................................................page 22

14.) Smoking Policy.................................................................................................page 23

15.) Visitor list.........................................................................................................page 24

16.) Possession List..................................................................................................page 25

17.) Privacy Form.....................................................................................................page 26-28

18.) Resident Rights.................................................................................................page 29

19.)Zero Tolerance Form..........................................................................................page 30

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PAPERWORK NEEDED FOR ADMISSION

1. ID

2. Birth Certificate (both mother and child)

3. Social Security Card (both mother and child)

4. Medicaid Cards (both mother and child)

5. Physical (both mother and child)

6. Proof of Pregnancy

7. Comprehensive Behavioral Assessment

8. Shot Records of Mother and Child

9. Shelter Petition ( If required)

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Emergency DATA SHEET (Mother)

Client Name:_____________________________

Date of Birth__________________ Social Security#:____________________________

Address:_______________________________________________________________________

______________________________________________________________________________

Allergies:______________________________________________________________________

______________________________________________________________________________

Medical Diagnosis: (e.g. -handicaps, diabetes, epilepsy, other conditions needing to be

mentioned in a medical emergency, etc):

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Medications Prescribed/Used:

______________________________________________________________________________

______________________________________________________________________________

Current Problems:

______________________________________________________________________________

______________________________________________________________________________

Other Information:

______________________________________________________________________________

______________________________________________________________________________

EMERGENY CONTACT/LEGAL GUARDIAN: ___________________________________________

Address of Contact:

______________________________________________________________________________

______________________________________________________________________________

Home Phone:________________________ Work Phone:_________________________

Relationship To Client:___________________________________________________________

Release of Information Obtained for Emergency Contact.

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Emergency DATA SHEET (Mother) - Continued:

Next of Kin:__________________________ Relationship:_________________________

Address:_______________________________________________________________________

______________________________________________________________________________

Phone:______________________________ Fax:________________________________


Other Contact:________________________ Relationship:_________________________

Address:_______________________________________________________________________

______________________________________________________________________________

Phone:______________________________ Fax:________________________________



Address:_______________________________________________________________________

______________________________________________________________________________

Phone:______________________________ Fax:________________________________


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ALPHA HOUSE OF PINELLAS COUNTY

701 5th Avenue North, St. Petersburg, FL 33701 Phone (727) 822-8190

AUTHORIZATION FOR DISCLOSURE OF CONFIDENTIAL INFORMATION – GENERAL

I, , DOB SS# (Resident Name)

Authorize ALPHA HOUSE OF PINELLAS COUNTY to disclose and/or communicate with:

(Provide Name and Address)

The following information: Note: Draw a line through information not needed.

Assessments, History and Physical, Medication Administration Records, Treatment Plan, Progress Notes, Lab Results, Discharge Summary and Continuing Care Plan, Other:

Purpose for the disclosure--be specific:

information will be disclosed in writing and/or verbally. Resident initial for FAX approval:

I understand that my records are protected under the Federal and State regulations governing the confidentiality and privacy of medical records and protected information under Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) 45 C.F.R., Parts 160 and 164 and cannot be disclosed without my written authorization unless otherwise provided for by the regulations. Any release of substance abuse information must be pursuant to 42 C.F.R., Part 2.

I also understand that I may revoke this authorization in writing at any time except to the extent that action has already been taken in reliance on it, and that in any event this authorization expires automatically after one year, unless otherwise stated below:

Date, event or condition of expiration:

I understand that generally ALPHA HOUSE OF PINELLAS COUNTY may not condition treatment on whether I sign an authorization, but that in certain limited circumstances I may be denied treatment if I do not sign this authorization. I also hereby release ALPHA HOUSE OF PINELLAS COUNTY from liability which may arise as a result of information disclosed under an authorization, if such information disclosed is later used to my detriment.

Date: Signature: Resident Signature

Date: Signature: Parent/Legal Guardian Signature

Date: Signature: Witness Signature (required)

PROHIBITION ON REDISCLOSURE: This information has been disclosed to you from records

whose confidentiality is protected. Any further disclosure is strictly prohibited. Florida Law

requires that any person, agency, or entity receiving information shall maintain such information

as confidential and exempt from the provisions of the public records law.

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AUTHORIZATION FOR DISCLOSURE OF CONFIDENTIAL INFORMATION – HEALTHY FAMILIES

I, , DOB SS# (Resident Name)

Authorize ALPHA HOUSE OF PINELLAS COUNTY and Healthy Families to communicate and disclose the following information to one another as necessary, in connection with their official duties in my case: Note: Draw a line through information not needed.

Assessments, Treatment Plan, Lab Results, Discharge Summary and Continuing Care Plan, Diagnosis, Attendance/Lack of Attendance, Progress/Cooperation, Successful/Unsuccessful Completion, Prognosis and Recommendations

Purpose for the disclosure: Service Coordination

Information will be disclosed in writing and/or verbally. Resident initial for FAX approval:




I understand that generally ALPHA HOUSE OF PINELLAS COUNTY Inc may not condition treatment on whether I sign an authorization, but that in certain limited circumstances I may be denied treatment if I do not sign this authorization. I also hereby release ALPHA HOUSE OF PINELLAS COUNTY from liability which may arise as a result of information disclosed under an authorization, if such information disclosed is later used to my detriment.





whose confidentiality is protected. Any further disclosure is strictly prohibited. Florida Law requires

that any person, agency, or entity receiving information shall maintain such information as

confidential and exempt from the provisions of the public records law.

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AUTHORIZATION FOR DISCLOSURE OF CONFIDENTIAL INFORMATION – DCF & Child Protective Custody

I, , DOB SS# ____________ (Resident Name)

Authorize ALPHA HOUSE OF PINELLAS COUNTY and the Department of Children and Families (DCF), Safe Childrens Coalition, Hillsborough Kids Inc., and Heartland for Children

To communicate and disclose the following information to one another as necessary, in connection with their official duties in my case:

Assessments, History and Physical, Medication Administration Records, Treatment Plan, Progress Notes, Lab Results, Discharge Summary and Continuing Care Plan, Any and All Records Needed.

Purpose for the disclosure: Service Coordination and Disposition of Child Custody





I understand that generally ALPHA HOUSEOF PINELLAS COUNTY Inc may not condition treatment on whether I sign an authorization, but that in certain limited circumstances I may be denied treatment if I do not sign this authorization. I also hereby release ALPHA HOUSE OF PINELLAS COUNTY Inc. from liability which may arise as a result of information disclosed under an authorization, if such information disclosed is later used to my detriment.






requires that any person, agency, or entity receiving information shall maintain such

information as confidential and exempt from the provisions of the public records law.

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AUTHORIZATION FOR DISCLOSURE OF CONFIDENTIAL INFORMATION – Emergency Contact

I, , DOB SS# ____________ (Resident Name)

Authorize Alpha House of Pinellas County, to disclose to:

(Provide Name and Address)

The following information: My presence in ALPHA and the circumstances of my need for Emergency care

Purpose for the disclosure: To inform above of my emergency status





I understand that generally ALPHA HOUSE OF PINELAS COUNTY may not condition treatment on whether I sign an authorization, but that in certain limited circumstances I may be denied treatment if I do not sign this authorization. I also hereby release ALPHA HOUSE OF PINELLAS COUNTY from liability which may arise as a result of information disclosed under an authorization, if such information disclosed is later used to my detriment.








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AUTHORIZATION FOR DISCLOSURE OF CONFIDENTIAL INFORMATION – DCF Benefits

I, , DOB SS# ____________

Authorize ALPHA HOUSE OF PINELLAS COUNTY to disclose to: Department of Children and Families - Assistance Benefits 525 Mirror Lake Dr. Suite 201 St. Petersburg, FL 33701

The following information: Resident identification data, income, assets, work status, and requested Information to help facilitate obtaining assistance for above Resident.

Purpose for the disclosure: To assist Resident as her authorized representative for benefits.













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AUTHORIZATION FOR DISCLOSURE OF CONFIDENTIAL INFORMATION – School Enrollment

I, , DOB SS# ____________

Authorize ALPHA HOUSE OF PINELLAS COUNTY, and the Pinellas County School System to communicate and disclose the following information to one another as necessary, in connection with their official duties in my case: Note: Draw a line through information not needed.

My name, DOB, SS#, ESE, Discipline Records, Current schedule, Attendance Records, Grades, Presence in ALPHA Program

Purpose for the disclosure: Enrollment in Pinellas County School and Service Coordination




Date, event or condition of expiration: UPON DISCHARGE





PROHIBITION ON REDISCLOSURE: This information has been disclosed to you from records whose

confidentiality is protected. Any further disclosure is strictly prohibited. Florida Law requires that any

person, agency, or entity receiving information shall maintain such information as confidential and

exempt from the provisions of the public records law.

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EXHIBIT A, PAGE ONE

HOMELESS VERIFICATION FORM Alpha, Inc

701 5th Avenue North

Client Name:_____________________________ Client Number:_____________________

Where did you sleep last night? Outside/street/park Shelter Other specify):_________________

Problems Presented/Verification: _________________________________________________________

_____________________________________________________________________________________

Verified by Case Worker: Yes Unable Date:_______________________

Eligible Criteria:

1. In places not meant for human habitation, such as cars, parks, sidewalks, abandoned building

(on the street).

2. In an emergency Shelter*.

*If an participant came from an institution but was less than 30 days and was living on the

street or in an emergency shelter before entering the facility, he/she should be counted in

either the street or shelter category, as appropriate.

3. In transitional or supportive housing for homeless persons and originally come from

the street/shelter.

4. Is being evicted within a week from a private dwelling until and no residence has been

identified and the person lacks the resources to obtain housing

5. Is being discharged within a week from an institution, such as a mental or substance

abuse treatment facility or a jail/prison, in which they had been a resident for more

than 30 consecutive days and no subsequent residence has been identified and the

person lacks the resources obtaining housing.

6. Is fleeing a domestic violence housing situation and the person lacks resources and

support needed to obtain housing.

How was this verified?:__________________________________________________________________________

_____________________________________________________________________________________________

_________________________ Case Worker's Signature

_________________________ Print Name

Disposition/Plan:_______________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

I, ______________________________verify I am without appropriate adequate housing opportunities. I further

state that my present living arrangements is temporary and I have no place to relocate at the present time. The

information I have provided and represented herein is correct and is a fair representation of my interview.

In addition I authorize the release of this information.

Signature:_______________________________ Date:___________________________

Print Name:_____________________________

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EXHIBIT A, PAGE TWO

DEMOGRAPHICS & INTERAGENCY REFERRAL FORM* Alpha, Inc

701 5th Avenue North

Personal Data Name:_____________________________ SSN:___________________ DOB:___________ Male Female

Name:_____________________________ SSN:___________________ DOB:___________ Male Female

Present Address:______________________________________________________ From:_______ To:_______

Present Address:______________________________________________________ From:_______ To:_______

Hispanic/Latino: Yes No

Race (Circle One): White Black/African American Native Hawaiian/Pacific Islander Asian

American Indian/Alaskan Native American Indian/Alaskan Native & White Asian & White

Black/African American & White American Indian/Alaskan Native & Black/African American

Other Multi-Racial

Education Level:______________________ __ Veteran (Yes or No)___________

Individual:_____________________ Family w/children:_______________ Couple w/o children:______________

Is Client Head of Household? Yes No Head of Household: Male Female

Number of persons needing services: Adults:______ Children:______

Gender/Ages: _____/_____ _____/_____ _____/_____ _____/______ _____/_____

Employment Data Status: Full Time:_____ Part-Time:_____ Day:_____ Temp______ None______

Applied for SSI/SSDI: Yes No Status: Pending_____ Received______ Denied____ On Appeal____

Resources Monthly Income: $_________ Work______ SSI/SSDI_______ TANF_______ Food Stamps_______

None_______ Other (specify)___________________________________________________________

HouseHold Characteristics (if applicable) Family Violence_________ Physically Disabled________ Drug Dependent_________ HIV/AIDS________

Developmentally Disabled_______ Alcohol Dependent_______ Chronically Mentally Ill__________

Other(specify)___________________________________________________________________________

Referral History Agency Referred to:______________________ Date Contact Person:__________ Phone Number:____________

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Emergency DATA SHEET (Child)

Client Name:_____________________________

Date of Birth__________________ Social Security#:____________________________

Address:_______________________________________________________________________

______________________________________________________________________________

Allergies:______________________________________________________________________

______________________________________________________________________________

Medical Diagnosis: (e.g. -handicaps, diabetes, epilepsy, other conditions needing to be

mentioned in a medical emergency, etc):

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Medications Prescribed/Used:

______________________________________________________________________________

______________________________________________________________________________

Current Problems:

______________________________________________________________________________

______________________________________________________________________________

Other Information:

______________________________________________________________________________

______________________________________________________________________________

EMERGENY CONTACT/LEGAL GUARDIAN: ___________________________________________

Address of Contact:

______________________________________________________________________________

______________________________________________________________________________

Home Phone:________________________ Work Phone:_________________________

Relationship To Client:___________________________________________________________


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Emergency DATA SHEET (Child) - Continued:

Next of Kin:__________________________ Relationship:_________________________

Address:_______________________________________________________________________

______________________________________________________________________________

Phone:______________________________ Fax:________________________________



Address:_______________________________________________________________________

______________________________________________________________________________

Phone:______________________________ Fax:________________________________



Address:_______________________________________________________________________

______________________________________________________________________________

Phone:______________________________ Fax:________________________________


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Emergency Medical Treatment

(Parental Permission for a Minor)

TO WHOM IT MAY CONCERN:

I hereby authorize emergency medical treatment for my child, ___________________________, who is

currently a resident at ALPHA HOUSE OF PINELLAS COUNTY located at 701 5th Avenue North, St.

Petersburg, Florida, 33701.

(subject to the limitations set forth in 39.407F.S for foster care residents). ALPHA, however, is not

responsible for payment of any of my child’s medical bills

This document releases the hospital and asks that treatment be provided.

_______________ ________________________________

Date Parent/Legal Guardian Signature

_______________ ________________________________

Date Witness Signature

_______________ ________________________________

Date Notary Public

Emergency Medical Treatment

(Permission for an Adult) TO WHOM IT MAY CONCERN:

I hereby authorize emergency medical treatment for myself. I am currently a resident at ALPHA HOUSE

OF PINELLAS COUNTY located at 701 5th Avenue North, St. Petersburg, Florida, 33701.

ALPHA, however, is not responsible for payment of any of my medical bills.

This document releases the hospital and asks that treatment be provided.

_______________ ________________________________

Date Resident Signature

_______________ ________________________________


_______________ ________________________________

Date Notary Public

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Guardianship Certification – Foster Care Residents

State of Florida, County of Pinellas (Complete if client is a minor AND IS in foster care)

I HEREBY CERTIFY that on this day, before me, an officer duly authorized in the State and County aforesaid to take acknowledgements, personally known to me or has produced ___________________________ as identification and who executed the foregoing instrument and acknowledged before me that they executed the same freely and voluntarily.

The undersigned Legal Guardian, hereby grants ALPHA HOUSE OF PINELLAS COUNTY staff permission to represent ________________________________ for the following activities:

• Enrollment and coordination of social service benefits

• Routine Medical and Dental care

• School enrollment and coordination of services

• Child care coordination

WITNESS my hand and official seal on _____ day of _______________, 20____.

__________________________________ _____________________ Signature of Parent or Guardian Date

__________________________________ _____________________ Signature of Resident Date

My Commission Expires:

___________________________ __________________________ Signature of Witness Signature of Notary Public

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BABY IN BED CONTRACT

I understand that sleeping with a baby in an adult bed or having a baby sleep alone in an adult bed is

NOT a safe parenting practice and is a potentially fatal situation. I also understand that sleeping with a

baby in an adult bed is against ALPHA’s policy of keeping babies and mothers safe and if I am found

doing so I can be discharged from the program.

By signing this contract I am agreeing to follow safe parenting practices by having my baby sleep in a crib

or a bassinet.

_______________________________________ __________________

Resident Signature Date

_______________________________________ __________________

Witness Signature Date

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Baby’s Birth Information

Mother’s Name: ________________________________________

Baby’s Legal Name:_____________________________________

Baby’s Date of Birth: ____________________________________

Baby’s Gender: MALE OR FEMALE (Circle One)

Baby’s Birth Weight & Length: ____________________________

Place of Delivery: ______________________________________

Type of Delivery: Vaginal or C-Section (Circle One)

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CELL PHONE POLICY

We trust your ability to make wise, responsible decisions for yourself and your wellbeing, and

encourage you to use this as an opportunity to learn valuable life skills of budgeting, effective time

management, and setting appropriate boundaries and discipline for yourself and those you keep in

contact with.

Please keep in mind, having and using a cell phone is a privilege not a right or necessity, and it is up

to you to handle it in a mature manner, showing ALPHA staff that you are able to manage effectively

this additional responsibility.

We strongly encourage you to consult with you case manager, counselor or life skills educator prior

to obtaining a cell phone and wireless plan to learn more about wireless services and determine

which kind of plan would best suit your needs. This will limit the possibility of unexpected talk-time

overages, which could leave you with a several hundred dollar bill.

I agree that signing the following will allow Alpha House of Pinellas County to enforce any rules

associated with my cell phone use.

I ___________________________ have reviewed and agree to abide by this policy.

Resident signature____________________________ Date_______________

Parent/Legal Guardian signature_______________________ Date_______________

Witness signature___________________________ Date________________

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Consent Form

I, ____________________________________, the parent or legal guardian of _____________________,

hereby give full consent for my child to enter ALPHA’s Transitional Living Program.

OR

I, ____________________________________, being of legal age give my full voluntary consent to enter

ALPHA’s Transitional Living Program.

By signing this form, I am granting full permission to live in, participate and attend all activities of the

Transitional Living Program.

_______________________________________ _______________

Signature of Parent/Legal Guardian Date

_______________________________________ _______________

Signature of Resident Date

_______________________________________ _______________

Signature of Witness Date

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ALPHAHOUSE OF PINELLAS COUNTY

Drug and Alcohol Screening Consent

This is a drug and alcohol free program. ALPHA does random Drug and Alcohol Screenings to ensure the

safety of each resident and their child. If a screening comes back positive, it constitutes grounds for

immediate discharge from the ALPHA program.

By signing this document, ___________________ is consenting to random Drug and Alcohol testing and

is accepting the results of the Drug and Alcohol Screening as a valid indicator of usage. The resident,

__________________, is acknowledging and accepting the consequences that follow the unsafe choice

made.

________________ ________________________________

Date Resident’s Signature

________________ ________________________________

Date Parent/Legal Guardian Signature (if applicable)

________________ ________________________________


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FILING A GRIEVANCE

You have the right to file a grievance to address situations you feel are

inappropriate or when you experience dissatisfaction with the program. There are no

consequences to filing a grievance. Here are the steps to take to resolve issues:

1. Talk to your counselor or case manager first about your concern. If after this

discussion you feel the issue has not been resolved move to step 2.

2. File a written grievance by completing the grievance form (staff may assist

you with this, if needed). Place the form in the provided envelope marked

“Confidential” and give it to the Program Manager.

3. The Program Manager has 5 working days to respond in writing.

4. You have 3 working days to reply to the Program Manager. If there is no reply

from you in 3 working days, the grievance is considered resolved.

5. If you are unsatisfied with the Program Manager’s response you may send

your grievance to the Director.

6. The Director has 5 working days to respond in writing.

7. You have 3 working days to respond to the Directors reply. If there is no reply

from you in 3 working days, the grievance is considered resolved.

8. If you are unsatisfied with the Director’s response you may keep a copy of

your grievance and address it again at a later date. Y

9. At any time in this process you may choose to take your grievance directly to

the Department of Children and Families or the Florida Local Advocacy

Committee.

I have been informed and understand the grievance process.

Resident Signature:___________________________ __Date:______________

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NO SMOKING POLICY

I have been informed of ALPHA’s no smoking on property policy. I understand that the following actions

will be taken if I am caught smoking on property:

1. The first time I get caught, I will be responsible for finding, attending, and transporting myself to

a smoking cessation class.

2. I will provide ALPHA with proof that I attended this class within one week of my offense.

3. I understand that if I am caught smoking on property again additional consequences will

be given up to and including discharge from the program.

By signing this contract, I am agreeing to follow ALPHA’s no smoking policy.

_____________________________________ ________________

Resident Signature Date

_____________________________________ ________________

Witness Signature Date

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Phone/Visitor List

Listed below are people you would like to have permission to visit while you are a resident of ALPHA:

Name Relationship Address Phone

______________ ____________________ ______________________ _____________

______________ ____________________ ______________________ _____________

______________ ____________________ ______________________ _____________

______________ ____________________ ______________________ _____________

______________ ____________________ ______________________ _____________

______________ ____________________ ______________________ _____________

______________ ____________________ ______________________ _____________

The following individuals are NOT authorized visitors:

Name Relationship Address Phone

______________ ____________________ ______________________ _____________

______________ ____________________ ______________________ _____________

______________ ____________________ ______________________ _____________

______________ ____________________ ______________________ _____________

______________ ____________________ ______________________ _____________

______________ ____________________ ______________________ _____________

______________ ____________________ ______________________ _____________

_________________ __________________________

Date Signature of Resident

_________________ __________________________

Date Signature of staff (for approval)

Page 25 of 31

RESIDENT POSSESSIONS LIST

NAME: ________________________________ DOB ________________ DATE____________

The following is a list of possessions that I brought to Alpha. I assume personal responsibility

for them and will remove all belongings upon discharge. I also understand that any items that

I leave at discharge will not be kept more than 30 days. At that point they will be given to the

outreach program.

Resident Signature & Date:_______________________________________________________________

Staff Signature & Date: __________________________________________________________________

Page 26 of 31

ALPHA HOUSE OF PINELLAS COUNTY NOTICE OF PRIVACY PRACTICES

As required by the Health Insurance Portability and Accountability Act (HIPAA)

You have a right to know how we use and share your personal information. This Notice tells you our responsibilities and your rights.

In order to provide you with the best possible care, all professional staff involved in your treatment and employees involved in the operations of the agency may have access to your records. All ALPHA HOUSE OF PINELLAS COUNTY employees follow these Privacy Policies.

Confidential Records

The personal information you gave us goes into a confidential (private) written record. We use it to plan for your counseling services and to receive payment for those services from our funding sources. Usually we must have your permission to use or share your personal information. Sometimes, for example, in safety situations we my share it without your permission. This is described more below. The permanent record is kept on paper. We will keep this for at least 7 years after you stop receiving services, and then your record will be destroyed. Some records and billing information are also stored in computers.

Our Responsibilities

• We will keep your information private

• We will follow these Privacy Practices

• We will give you a copy of our Notice of Privacy Practices

• If our Privacy Practices change, we will give you a new copy at your next scheduled appointment or whenever you request one.

How We Use and Share Your Personal Information There are three ways we use and share information about you. The three ways are to 1) Provide services, with your consent. When you apply for services, you are asked to sign Consent for

Treatment. With this consent, we can use and share information about you in these ways:

a) For treatment and services we may use and share information about you with professionals and agencies who serve you. For example, we will use information about you during staff supervision so that we can ensure that you are getting the best services we can provide. We may share information with team members so that everyone can be sure they are working on the same goals.

b) For Payment. We may use and share information about you to obtain payment for services we have provided to you. For example, we may give information to those agencies that provide funding to our programs.

c) For Quality Improvement. We may use and share information about you in order to make sure we are providing good services. For example, we may give information to our peer review teams so they can make sure you are receiving proper services.

2) Provide information to others who need it, with your approval. If we need to share personal information about you for other reasons, we will ask you to sign an Authorization Form to give your approval. This will tell you what information we need to share, who will receive it, and why. For example, you need to sign an Authorization Form for us to share information with your child’s school if you want us to talk with the teacher. Your approval is only good until the date stated on the form, not forever. If you change your mind, tell us in writing and we will not share the information.

This Notice describes how medical and other information about you may be used and disclosed and how you can get

access to this information. Please read it carefully.

Page 27 of 31

3) Provide information to others who need it, without your consent or approval. We may sometimes share personal information about you with your approval. We will do this only when it is lawful and will not share any more information than necessary. The Department of Health and Human Services requires us to list specific situations in which one’s personal information might be released. Most of these situations are not those in which ALPHA HOUSE OF PINELLAS COUNTY would be involved with your family. We have highlighted in bold those situations in which we may be involved.

• Appointments – for appointment reminders or notification when an appointment must be cancelled or rescheduled

• Emergency Treatment – when you need medical care in a crisis

• Health and Safety – to prevent or reduce a serious threat to someone’s health or safety. We will do what is necessary to protect you and others.

• Oversight – when we are reviewed by licensing and accreditation agencies or auditors

• Research – for approved research purposes. A Board must review the research to make sure your information remains private (and you must give consent to participate in any research here at ALPHA HOUSE OF PINELLAS COUNTY)

• Legal Proceedings- in response to court orders and other legal actions

• Law Enforcement – if you are missing or in danger. Law enforcement may have access to your information for legal or civil proceedings.

• Abuse or Neglect - to report suspected abuse, neglect or exploitation of any child or vulnerable adult

• Government – to government regulatory agencies, including national security and intelligence agencies

• Required by Law – at other times when the law requires us to

• Public Health – to report diseases, drug reactions or other public health concerns

• Funeral Directors – to the funeral director who will take care of your body

• Organ Donation – for organ, eye or tissue donation purposes

• Coroners – to a coroner or medical examiner for identification or other purposes

• Workers’ Compensation – to process a Workers’ Compensation claim

Your Rights You have a right to read your record and to have a copy of its contents if you would like. We may charge a fee for copying, mailing and supplies. Under limited circumstances, your request may be denied. You have the right to correct information in the record that you believe is inaccurate by providing a correction statement.

You have the right to request that certain information not be shared, although ALPHA HOUSE OF PINELLAS COUNTY is not required to follow your request. If we agree, we will comply with your request unless the information is needed for an emergency.

You have the right to confidential communications. You may request that we communicate with you in a certain way or at a certain location. This request needs to be made in writing.

You have the right to receive a list of the disclosures of your personal information that have been made for reasons other than for treatment or healthcare operations. This listing begins on April 14, 2003.

You have the right to refuse certain types of treatment or services. If we have alternate services available, you can continue to receive those services at this agency.

We will not use your personal information for any marketing purposes. We would only use your photo or comments in any of the agency’s materials (brochures, videos, etc.) with your written permission. At times, we have asked participants to appear with us at public forums but your refusal to do this would not impact your receiving services at ALPHA HOUSE OF PINELLAS COUNTY.

If you believe your rights have been violated, you may file a complaint with ALPHA HOUSE OF PINELLAS COUNTY or with the HHS office of Civil Rights. You will not be penalized for making a complaint.

Page 28 of 31

If you have any questions, would like to request restrictions on uses and disclosure for health care treatment or operations, or would like to file a complaint, please contact our Privacy Officer, (ALPHA Director), (727) 822-8190

Your signature on this form does not indicate your agreement with the information provided. It acknowledges that you have received and read ALPHA HOUSE OF PINELLAS COUNTY Notice of Privacy Practices.

_________________________________________ __________________ Client Signature Date _________________________________________ __________________ Parent/Guardian Signature Date _________________________________________ ___________________ Witness Signature Date

Page 29 of 31

Resident Rights

As a resident of ALPHA HOUSE OF PINELLAS COUNTY you have the following rights:

1) To be treated by the staff with respect and dignity

2) To equal treatment regardless of race, sex, sexual orientation, ethnic

group, religion, age, or handicap

3) To confidentiality of information released except as allowed/required by

law

4) To refuse any intervention (i.e. medication) and to be informed of the consequences of such

refusal

5) To have a Treatment Plan developed based on your individual needs

6) To participate in the development of and be offered a copy of your Treatment ,Case

Management, and Life Skill Plans

7) To be assured of freedom from neglect, abuse, exploitation or any form of corporal

punishment

8) To be assured that any search or seizure of contraband is carried out in a manner consistent,

with program standards to ensure safety, security and the well being of clients and staff

9) To initiate a grievance and to be heard by representatives of Alpha You may ask for and

receive a copy of ALPHA HOUSE OF PINELLAS COUNTY grievance Policy and follow the

grievance process. You may contact Department of Children and Families directly (800-962-

2873), your attorney, or the Florida Local Advocacy Council (800-342-0825) at any time.

I have read, understand, and have received a copy of this Client’s Rights form.

_________________________ __________________________ Date Resident Signature

__________________________ __________________________ Date Parent/Guardian Signature (if applicable)

__________________________ __________________________ Date Witness

Page 30 of 31


ZERO TOLERANCE CONTRACT

I understand the ALPHA Transitional Living Program is a SAFE PLACE for everyone and that I

have the responsibility to myself, the staff and other residents to behave in a lawful manner. I

understand that ALPHA has zero tolerance for the following actions and that the following

actions are flagrant enough to warrant immediate dismissal.

• Battery upon any resident or staff person (hitting, striking, punching, slugging, pushing etc.)

• Deliberate property damage (punching walls, ripping our doors, etc.)

• Possession of alcohol, drugs, knives, or guns (having illegal objects in my possession)

• Theft of anyone’s property (taking money, clothing, personal belongings, etc.)

• Child abuse or neglect

• Any illegal activity

I agree to notify staff immediately of any actions that make this residence unsafe for anyone at

any time. I have read and understand the above rules. I am willing to keep ALPHA’s

Transitional Living Program safe.

____________________ ________________________________

Date Resident Signature

____________________ ________________________________

Date Parent/Legal Guardian Signature

(if applicable)

____________________ ________________________________


Documents

Child Intake Packet - ALPHA House of Pinellas Countyalphahousepinellas.org/wp-content/uploads/2016/10/Child...Page 7 of 31 ALPHA HOUSE OF PINELLAS COUNTY 701 5th Avenue North, St